Timbers Of Jasper The

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were given as ordered and a discharged resident was sent home with the correct medication for 1 of 3 closed records reviewed. A blood thinner was not given as ordered, and a resident was sent home with another resident's medications at discharge. (Resident B)On 1/30/26 at 4:00 P.M., the Administrator provided an incident form that indicated on 9/19/25 when Resident B was discharged from the facility, medications belonging to another resident had been sent home with them.

The form indicated the facility attempted to contact Resident B's representative several times daily until 9/25/25 when contact was made and the medication was brought back to the facility the same day. On 1/29/26 at 11:32 A.M., Resident B's clinical record was reviewed.

Resident B was admitted to the facility on [DATE] and discharged on 9/19/25.

Diagnosis included, but was not limited to, fracture of the right lower leg.

The most recent admission minimum data set (MDS) assessment, dated 9/11/25, indicated no cognitive impairment and no behaviors.

Resident B required substantial to maximal assistance (helper does more than half the effort) with toileting, showering, and transfers.

Physician orders included, but were not limited to: enoxaparin (a blood thinner) syringe; 30 mg (milligrams)/0.3 mL (milliliters); administer 30 mg/03 mL; subcutaneous, dated 9/5/25 and discontinued 9/19/25.

Resident B's Medication Administration Record (MAR) indicated enoxaparin had not been given on the following days: 9/14/25 unavailable 9/15/25 unavailable, awaiting delivery 9/16/25 unavailable 9/18/25 blank, no note A discharge progress note, dated 9/19/25, indicated Resident was discharged home with all medications, signed by Licensed Practical Nurse (LPN) 3. On 1/30/26 at 10:29 A.M., the Emergency Drug Kit (EDK) machine was observed with LPN 5.

The EDK contained enoxaparin 30 mg/0.3 mL syringe. At that time, LPN 5 indicated the machine was kept stocked, and if staff noticed it was running low on something, they would contact the pharmacy and they would be in either that day or the next day to restock it. LPN 5 also indicated when a resident was discharged with medications, two nurses would check that the medications sent home were correct and both would sign the discharge summary form. On 1/30/25 at 11:43 A.M., the Director of Nursing (DON) indicated LPN 3 was no longer on staff at the facility. At that time, she provided the discharge summary form for Resident B.

The form was signed on 9/19/25 by Resident B's representative and one nurse, LPN 3. On 1/30/26 at 1:30 P.M., the Administrator provided a current Medication Administration competency form, last revised 4/25, that indicated medications should be administered as ordered.

This deficiency relates to Intake 2622137. 3.1-25(a)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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